__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use Many terms used in discussions of opioid use and misuse may have ambiguous meanings ( Table 1 ). The absence of consensus in the terminology and definitions of substance use, substance use disorders, and addiction has led to considerable confusion and misconceptions ( Table 2 ). These misconcep- tions may be harbored by clinicians, patients, family members, and the public and can negatively impact patient interaction, assessment, treatment, and out- comes. Correction of these erroneous beliefs and attitudes is important, as is the use of nonpejora- tive and nonstigmatizing language when describing opioid analgesics, the patients who need them, and patients who develop aberrant behaviors or addic- tion involving opioids ( Table 3 ). Pejorative termi- nology has a strong negative effect on patients and serves to reinforce their sense of shame and stigma over using opioid analgesics. These terms signal a negative attitude and judgment to patients [15; 19]. BEHAVIORAL RESPONSES TO PRESCRIBED OPIOIDS Patients with pain display a continuum of behavioral responses to prescribed opioids. Some develop aber- rant behaviors, which are defined as unintended behaviors involving the acquisition or use of prescribed opioids [22]. Depending on the study, researchers have reported that as many as 40% of patients with pain receiving opioid therapy exhibit aberrant behavior; however, in only a minority of these patients does the aberrant behavior reflect an emerging opioid use disorder. It is important to distinguish the underlying basis and the level of risk for opioid use disorder represented in the aber- rant behavior. This is accomplished by differential diagnosis ( Table 4 ). To capture the perspective of pain practitioner viewpoints in associating aberrant behaviors and risk of patient opioid problems, 100 pain physicians were instructed to rank a list of 13 aberrant drug-use behaviors from least to most sug- gestive of emergent opioid use disorder. Selling the prescribed opioid and prescription forgery received highest ranking as most aberrant, and altered route
OPIOID USE TERMINOLOGY
Term
Definition
Misuse, nonmedical use
Use of the opioid that departs from intended prescribing by the provider
Abuse
A maladaptive pattern of opioid use with the primary intent of achieving euphoria or getting high A primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Characterized by behavior including impaired control over drug use, compulsive drug use, continued use despite harm, and drug craving. The expected response to chronic administration of many drug classes such as opioids, anabolic steroids, and beta-blockers, manifesting in neurologic adaptation whereby a drug class-specific withdrawal syndrome is produced by abrupt cessation, rapid dose reduction, decreased blood concentration, or antagonist administration
Addiction
Physical dependence
Tolerance A state of adaptation in which the physiologic changes from drug exposure over time lead to diminished drug effect Pseudoaddiction An iatrogenic condition whereby patients display aberrant drug-seeking behaviors mimicking opioid use disorder but driven by intense need for pain relief. Resolves with adequate pain relief. Diversion Transfer of a controlled substance from authorized to unauthorized possession or distribution Opioid Any compound that binds to an opioid receptor in the CNS, including naturally occurring, synthetic, and semi-synthetic opioid drugs and endogenous opioid peptides Iatrogenic A response, usually unfavorable, to a medical or surgical treatment induced by the treatment itself CNS = central nervous system. Source: [10; 20; 21] Table 1
7
MDMS1526
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